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metabolic dysfunction liver

How metabolic dysfunction may be harming your health

Research indicates that an increasing number of thin people have metabolic dysfunction, which gives rise to obesity, diabetes, high blood pressure, and other elements of metabolic syndrome

By Dr. Ana Maria Kausel, MD
And Dr. Sarah Musleh, MD

In health and nutrition, looks can be deceiving. That rail-thin model may have metabolic dysfunction. And the green juice she’s drinking—which could contain as much sugar as a Krispy Kreme doughnut—may be partially to blame.

Metabolic dysfunction has many manifestations and being overweight is just one of them. That’s because many people do not become obese, then develop metabolic dysfunction. They develop metabolic dysfunction, and one of its manifestations is obesity.

Unlike obesity, the majority of the manifestations of metabolic dysfunction are invisible to the naked eye. And increasingly, it’s hidden sugar—specifically fructose—that’s driving the rise of metabolic dysfunction.

The good news is that there are steps people can take to mitigate the risks of metabolic dysfunction. Reversing metabolic dysfunction starts with changing what we eat. But before we address diet, it’s helpful to first define metabolic dysfunction and explain why it occurs.

What is metabolic dysfunction?

To understand metabolic dysfunction, you need to understand metabolic syndrome. Metabolic syndrome is a constellation of disorders that, when occurring together, increase a person’s risk of diabetes, stroke, coronary heart disease, and other health issues.1Swarup S, Goyal A, Grigorova Y, Zeltser R. Metabolic syndrome. StatPearls. National Library of Medicine. Updated May 2, 2022. Accessed November 14, 2022.

Metabolic dysfunction can give rise to metabolic syndrome. A person has metabolic syndrome if they have any three of the following elements of metabolic dysfunction:2Swarup S, Goyal A, Grigorova Y, Zeltser R. Metabolic syndrome. StatPearls. National Library of Medicine. Updated May 2, 2022. Accessed November 14, 2022.

  • A waist circumference of more than 35 inches in women and 40 inches in men
  • Hypertriglyceridemia, also known as high triglycerides
  • Low levels of HDL, also known as good cholesterol
  • Hyperglycemia, also known as high blood sugar
  • Hypertension, also known as high blood pressure

Waist circumference is the only visible manifestation of metabolic dysfunction. Based on our clinical experience, few patients with metabolic dysfunction have waists that are large enough to meet the criteria. The rest of the criteria can only be uncovered by a blood panel and often go undetected. But increasingly, thin people are surprised by what a blood panel reveals.

Visible and invisible metabolic dysfunction

Nonalcoholic fatty liver disease (NAFLD) is one of the invisible manifestations of metabolic dysfunction. A common disease affecting about 24% of US adults, NAFLD occurs when excess fat accumulates in the liver.3Definition & facts of NAFLD & NASH. National Institutes of Diabetes and Digestive and Kidney Diseases. Updated April 2021. Accessed November 14, 2022. 

There are two types of NAFLD: nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). In NAFL, fat accumulates in the liver, but it doesn’t lead to inflammation or liver damage. In NASH, the fat accumulation harms the liver, leading to fibrosis, or cirrhosis. Both conditions do not stem from alcohol use.4Definition & facts of NAFLD & NASH. National Institutes of Diabetes and Digestive and Kidney Diseases. Updated April 2021. Accessed November 14, 2022.

Typically, NAFLD is associated with conditions such as type 2 diabetes and obesity.2 It’s estimated that about 75% of patients who are overweight and between 90% and 95% of patients who have morbid obesity also have NAFLD.5Cotter TG, Rinella M. Nonalcoholic fatty liver disease 2020: The state of the disease. Gastroenterology. 2020;158(7):1851-1864.

But it isn’t just people who are struggling with their weight who have this disease. Rates of NAFLD among people who are lean or who have a normal BMI tell an interesting tale. Globally, an estimated 9.6% to 27% of lean people or people with a normal BMI have NAFLD.6Kumar R, Mohan S. Non-alcoholic fatty liver disease in lean subjects: characteristics and implications. Journal of Clinical and Translational Hepatology. 2017;XX(XX):1-8. This is noteworthy because as we mentioned in our previous article, being thin does not equate with being healthy. 

The other markers of metabolic dysfunction are also difficult to spot without a physical examination and/or a blood panel. In addition to the estimated 25.9% of American adults who have high triglyceride levels,7Fan W, Philip S, Granowitz C, Toth PP, Wong ND. Prevalence of US Adults with Triglycerides ≥ 150 mg/dl: NHANES 2007–2014. Cardiol Ther. 2020;9(1):207-213. 19% have low HDL,8Prevalence of low high-density lipoprotein cholesterol among adults, by physical activity: United States, 2011-2014. Centers for Disease Control and Prevention. March 2017. 11.3% have diabetes,9National diabetes statistics report. Centers for Disease Control and Prevention. Updated June 29, 2022. Accessed November 16, 2022. 38% have prediabetes,10National diabetes statistics report. Centers for Disease Control and Prevention. Updated June 29, 2022. Accessed November 16, 2022. and 47% have high blood pressure.11Facts about hypertension. Centers for Disease Control and Prevention. Updated October 14, 2022. Accessed November 16, 2022.

These widespread indicators of metabolic dysfunction point toward a much bigger problem—one you may encounter every time you decide what to eat.

Visible and invisible sugar

What’s a healthier breakfast: A Jamba Juice Matcha Green Tea Blast smoothie, or an Original Glazed Krispy Kreme Doughnut? Surprisingly, if you’re concerned about calories and sugar intake, you might be better off choosing the doughnut.

With no add-ons, the smoothie contains 410 calories, 51 grams of sugar, and only 1 gram of fiber.12Matcha green tea blast. Jamba Juice. Accessed November 16, 2022. The doughnut, on the other hand, has 190 calories, 10 grams of sugar, and no fiber.13Krispy Kreme doughnuts nutritional information. Updated January 14, 2013. Accessed November 16, 2022. You read that right: The green smoothie contains more sugar than five Krispy Kreme doughnuts.

But it isn’t just smoothies that are to blame. Search hard enough, and you’ll find this hidden sugar almost everywhere. It’s in many highly processed and packaged foods in the forms of sucrose and fructose. Common sources include soda, juices, fast food, condiments, jams, and breads. Many staples of the American diet also include sucrose, better known as table sugar, which is half glucose and half fructose.14Sucrose. PubChem. National Library of Medicine. Accessed November 16, 2022.

All of that fructose is driving the uptick in NAFLD with increases in hypertriglyceridemia (high triglycerides).15Ouyang X, Cirillo P, Sautin Y, et al. Fructose consumption as a risk factor for non-alcoholic fatty liver disease. Journal of Hepatology. 2008;48(6):993-999. This is because the liver metabolizes 70% of fructose. The organ can only metabolize so much before it begins to store fat, leading to NAFLD.16Muriel P, López-Sánchez P, Ramos-Tovar E. Fructose and the liver. Int J Mol Sci. 2021;22(13):6969. This is how people end up with little to no visceral (belly) fat, but all of the other markers of metabolic dysfunction.

How do we prevent metabolic dysfunction?

Preventing metabolic dysfunction starts with diet. But before you Google the latest fad diet, know that it’s challenging to completely avoid fructose and sucrose. They’re too ubiquitous. At Anzara Health, we counsel patients with a simple piece of nutritional guidance: Protect the liver, feed the gut.

The idea was pioneered by pediatric neuroendocrinologist Robert Lustig, MD, whom you might recognize from the viral video, “Sugar: The Bitter Truth.” Lustig’s theory is that we can protect the liver by consuming less fructose and feed the gut’s microbiota by consuming more fiber. 

To protect their livers and feed their guts, we counsel our patients to abide by the 30-30, 3-3 rule. The rule is simple: Every day, you should eat at least 30 grams of fiber and consume no more than 30 grams of sugar. 

The 3-3 rule applies to any packaged foods, because we all need a diet that works when we’re stuck in traffic or trying to grab a bite to eat on our way to work. If you’re eating anything processed or packaged, it should have no more than 3 grams of sugar and must have at least 3 grams of fiber.

Is this the silver bullet that will slay metabolic dysfunction? No. But abiding by this rule will help clean up your diet and protect your liver. Ultimately, we want our patients to eat whole, unprocessed foods that are nutritionally dense and rich in fiber. 

The 30-30, 3-3 rule is a step in the right direction, but comprehensive nutritional change requires some education, as well as some new habits. Ultimately, both can prevent or correct metabolic dysfunction.

Curious about your metabolic health or interested in making healthier lifestyle choices? Schedule your appointment with our best-in-class, board-certified endocrinologists to begin your journey to better health.



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